Hereditary breast cancer who to refer to a cancer genetics clinic and how to counsel patients with

Transcription

1 Hereditary breast cancer who to refer to a cancer genetics clinic and how to counsel patients with positive and negative results? SAMO Workshop Luzern 3./ Dr. med. Barbara Bolliger TumorTumor- und Brustzentrum ZeTuP

2 Hereditary Breast Cancer

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5 Incidence of hereditary breast cancer sporadic familiar genetic

6 BRCA1/BRCA2

7 Counts of breast and ovarian cancer by mutation location within BRCA1 for all 356 PT mutations Thompson D et al. Cancer Epidemiol Biomarkers Prev 2002;11: by American Association for Cancer Research

8 Cumulative risks of breast cancer, ovarian cancer, and cancer of either site for relatives with BRCA1 or BRCA2 mutations, based on cancer site in the index case BRCA1 BRCA1 BRCA2 BRCA2 Simchoni S et al. PNAS 2006;103: by National Academy of Sciences

9 Gene mutations associated with a increased breast cancer incidence

10 Who to refer to a cancer genetics clinic?

11 Risk Assessment for breast cancer of genetic origin: Family history Breast cancer diagnosed before age 50 years or ovarian cancer at any age First or second degree relatives diagnosed with breast cancer before age 50 years or diagnosis of ovarian cancer at any age Bilateral breast cancers in the family Breast and ovarian cancer in the same family or same woman Cases of male breast cancer in the family Cancer in a very young age Proven BRCA1/2-mutation in the family Ashkenazi Jewish ethnicity Two or more types of BRCA1 or BRCA2-related cancers in a single family member Triple negative breast cancer under age 60 years

12 Associated cancers BRCA1 BRCA2 Breast cancer 65-87% - Bilateral breast cancer up to 60% Breast cancer 40-50% Male breast cancer Ovarian cancer/cancer of the Fallopian tube/primary peritoneal cancer 40% Ovarian cancer about 10% Colon Pancreatic cancer Gallbladder cancer Gastric cancer Prostate cancer Melanoma

13 Models for assessment of breast/ovarian cancer risk and the probability of positive genetic testing BRCAPro-Model (CaGene6) cagene/ Tyrer-Cuzick Model (IBIS- Modell) BOADICEA Myriad-Model

14 Guidelines: NCCN

15 Guidelines: ESMO

16 Three Generation Pedigree Cancer cases Primary tumours Metastasis Bilateral breast cancer? Age of diagnosis if possible: confirmation of the data with records

17 CaGene 6: X.Y., 38 years

18 Cagene 6: X.Y., 38 years

19 Genetic Testing Blood sample Costs: reimbursement from health insurance, previous Kostengutsprache recommendable Costs of a complete analysis of the BRCA1/2 Gene Costs of the analysis of a known mutation276. Laboratories in Switzerland: University of Geneva KS Aarau Labor Genetica Zürich Duration of analysis: about two weeks

20 How to counsel patients with a positive result?

21 A deleterious BRCA- Mutation found The risk of breast and/or ovarian cancer is significantly increased Risk reducing procedures has to be discussed: Risk adapted surveillance program Prophylactic surgery Chemoprevention Other family members can be tested

22 Surveillance of BRCA1/2 positive patients Examination Frequency Start with Breast self examination monthly 18 years Breast ultrasound Every 6 month 25 years MRI of the breast yearly 25 years Mammography yearly, alternating with 30 years MRI Gynecological Every 6 month examination with vaginal ultrasound and Ca125 examination 30 years Coloscopie 50 years Every 5 to 10 years

23 Cancer risk reduction methods

24 Prophylactic mastectomy for prevention of breast cancer (2010) 39 observational studies were included, data on 7384 women No randomized trials Reduction of breast cancer and/or disease specific mortality after bilateral prophylactic mastectomy (BPM) particularly for those with BRCA1/2- mutation CPM reduces the incidence of contralateral breast cancer, but the data were inconsistent about improvement in disease specific survival Psychological measures: high levels of satisfaction with the decision, but less with the cosmetic results, less worries over breast cancer after BPM

25 Prophylactic mastectomy for for prevention of breast cancer (2010) Authors summary: Women should be aware of their true risk developing breast cancer and the limitation of current evidence when considering prophylactic mastectomy The studies have methodological limitations Many additional surgeries needed Less cancer worries, but they may overestimate their cancer risk Insufficient evidence for improvement of survival with CPM

26 Efficacy of risk-reducing mastectomy (RRM) on overall survival (OS) in BRCA1/2-associated breast cancer (BC) patients Kaplan Meier estimates for time to onset of breast cancer (A) or death by all causes (B) Heemskerk-Gerritsen, Ann Oncol 2013

27 Risk-Reducing Salpingo-Oophorectomy for the Prevention of BRCA1- and BRCA2-Associated Breast and Gynecologic Cancer: A Multicenter, Prospective Study Kauf N et al, JCO 2008

28 Risk-Reducing Salpingo-Oophorectomy for the Prevention of BRCA1- and BRCA2-Associated Breast and Gynecologic Cancer: A Multicenter, Prospective Study Kauf N et al, JCO 2008

29 The National Comprehensive Cancer Network: Guideline (2013) Discuss risk-reducing mastectomy and recommend risk-reducing salpingo-oophorectomy, ideally between 35 and 40 years of age, and upon completion of child bearing, or individualized based on earliest age of onset of ovarian cancer in the family

30 Standford Decision Tool:

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32 Associations between oral contraceptivs and ovarian cancer among BRCA1mutation carriers (A), BRCA2 mutation carriers (B) and BRCA1and BRCA2 mutation carriers combined Moorman P G et al., JCO2013

33 Association between oral contraceptives and breast cancer among BRCA1 mutation carriers (A), BRCA2 mutation carriers (B) and BRCA1 and2 mutation carriers combined Moorman P G et al., JCO 2013

34 Chemoprevention Agent Indication Studies Tamoxifen Treatment and prevention of BC IBIS-1, Italian, NSABP-P1, Royal Marsden, STAR Raloxifen Osteoporosis Royal Marsden, MORE, CORE, RUTH, STAR Arzoxifen (BC prevention, osteoporosis) GENERATION Lasofoxifene Osteoporosis (Europa) PEARL Exemestane Treatment of BC MAP.3 Anastrozole Treatment of BC IBIS-2

35 TAM and BRCA1/2- Mutations: Results from the NSABP- B1- Study 288 women with BC/13388 participants

36 ASCO Breast Cancer Risk Reduction Guideline Update Visvanathan, JCO, 2013 Risk reduction for BRCA1 and 2 Mutation carriers: There are insufficient data on efficacy of Tamoxifen for breast cancer risk reduction in BRCA1 and 2 mutation carriers to give reliable estimates of their effect in this setting. The 2009 guideline describes the finding from phase III randomized trials of Tamoxifen use and breast cancer incidence among women with inherited mutations in BRCA1 and BRCA2. To date, there are no data from phase III randomized trials on the preventive effect of Raloxifen an AI s especially in BRCA1 and 2 mutation carriers

37 How to counsel patients with a negative result?

38 No deleterious BRCA-Mutation was found Known BRCA- Mutation in the family: The breast and ovarian cancer risk is not increased and is equal to the general population no special surveillance is needed No known BRCA- Mutation in the family: The breast and ovarian cancer risk is significantly decreased A genetic risk can not be excluded The further recommendations are according the the personal and familiar history

39 Take Home Message Only a small number of our breast cancer patients have a genetic risk The family history should have a specific pattern Woman with a possibly genetic cancer risk should be identified and referred for genetic counseling Genetic testing and recommendation for risk adapted surveillance according to the specific situation Discussion of other risk reducing strategies in patients with a proven BRCA-mutation Internet based tools can help us

40 We are able to identify a genetic cancer risk and can prevent cancer!